Private Fee for Service

Medicare Private Fee-for-Service (PFFS) is another type of Medicare Advantage (Part C) plan sold by private insurers. PFFS plans are different from Original Medicare and Medigap. This page will look at the costs and coverage so you can decide if this program is a good fit for you. Then, you can confirm with Lacayo Group Insurance whether a PFFS plan is offered in your area.

What Do PFFS Plans Cover?

All Medicare Advantage plans are required to offer the same coverage as Original Medicare. Your plan may include extra benefits like dental, vision, or prescription drug coverage.

🚨 The PFFS plan dictates how much it will pay doctors, hospitals, and other healthcare providers, and how much YOU must pay when you receive care.

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PFFS Plans: Pros and Cons

Medicare PFFS members are not typically limited to a network. Most plans will contract with ANY Medicare-approved provider that accepts its payment terms, giving you more freedom and flexibility to choose.

Note: All providers MUST accept PFFS members if it’s a medical emergency.

On the other hand, it might be difficult to find a provider in your area that accepts your PFFS plan, and you may have to confirm at each visit whether the provider will cover the service. Some plans also allow providers to balance-bill. Balance billing means you might be responsible for paying up to 15% over what your plan pays for the service — in addition to the required copays and deductibles.

Private Fee-for-Service Plans

👍 You get a better overall choice of providers than a PPO or an HMO.

👍 If your plan doesn’t include Part D coverage, you can add a Medicare prescription drug plan during the AEP.

👎 You may have a hard time finding a provider in your area that accepts your plan.

👎 Your plan could have higher out-of-pocket costs than PPOs or HMOs.

Understanding Your Costs

Under a PFFS plan, you’ll be responsible for any copays and coinsurance, set by your plan, when you receive the service — besides premium costs. Then the provider will bill your plan for the leftover amount. If your plan allows balance billing, you’ll pay the remaining balance or the difference between the amount the provider charges and what the plan reimburses.

You only have to pay the copay or coinsurance amount that the plan allows for the service type(s) you get at the time of the service.

What Else You Should Know About PFFS Plans

When you join, you’ll get a plan membership ID card which you should show every time you visit a medical provider. Your provider can choose whether to accept the plan’s terms and conditions for payment. This card is different from your red, white, and blue Original Medicare card.

Some PFFS plans contract with a network that always agrees to treat you — even if you haven’t seen them before.

But not all providers will agree to accept the plan’s payment terms. Out-of-network providers may choose not to treat you even if you’ve been there before.

Here are some other frequently asked questions:

Which Medicare Advantage Plan Is Best for Me?

The best Advantage plan for you will mostly depend on the choices in your area and what your needs are. If seeing a certain doctor matters to you, make sure the provider accepts any Advantage plan that interests you.

Talk to a Licensed Insurance Agent

Medicare Advantage plans can vary in what they cover and how much you pay. Plus, not every program is available where you live. That’s why Lacayo Group Insurance is here to help. Our licensed agents will shop around and compare plans to find you the best available coverage for your individual needs. Don’t wait — call the number on your screen today!

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